Advanced Practice Leader, Accreditation and Quality Improvement

This new Advance Practice Lead for Accreditation is responsible for organization-wide accreditation and regulatory compliance initiatives. The focus of the role is developing and implementing organizational initiatives to support accreditation and compliance readiness. Promotes a continuous readiness program that emphasizes quality and patient safety at the forefront of regulatory compliance. Under the direction of the Senior Clinical Director, Quality and Professional Practice, oversees the daily accreditation program and workflow and supports Quality Improvement initiatives. Collaborates with operational and executive leaders, accreditation and regulatory specialists, content matter experts and frontline staff to develop an effective accreditation and compliance readiness infrastructure that ensures the organizational goals are met and sustained. Explores opportunities for standardizing organizational readiness for regulatory compliance activities. Collaborates closely with colleagues on a national level to enhance SE Health accreditation readiness. Collaborates with key internal and external stakeholders to address and sustain evidence-informed practice and safety culture.

**Major responsibilities**:
**Accreditation responsibilities**:

- Lead organizational readiness
- Lead the planning, implementation and evaluation of SE Health readiness and processes to ensure accreditation by status accrediting organizations such as Accreditation Canada as well as other regulatory standards or certifications
- Lead organization-wide accreditation and regulatory compliance initiatives
- Support accreditation needs and develop content expertise and resources
- Collaborate with accreditation and regulatory specialists to review work plans and progress
- Identify gaps and areas for growth or improvement to ensure accreditation initiatives are met
- Collaborate with other departments/business lines to ensure regulatory functions are addressed
- Lead/manage meetings and activities of the Accreditation Planning Committees
- Oversees project prioritization and timeline management of the Accreditation Canada project
- Focus on coordinating work with operational and service partners to meet Accreditation Standards and Required Organizational Practices (ROPs)

**Resource development and management**
- Develop education and resources and provides presentations related to accreditation and other regulatory compliance initiatives
- Ensure accreditation and regulatory resource are recent and up to date
- Develop and implement activities to monitor and evaluate compliance with accreditation and regulatory standards through ongoing organizational assessment
- Oversee the organizational communication and education plan for accreditation (e.g. resource/webpage management, survey updates, tracers, etc.)
- Collaborate with external partners of SE Health
- Plan and coordinate the accreditation and/or regulatory survey
- Manage communication and agendas for onsite survey activities
- Manage logistics of onsite accreditation and regulatory surveys
- Manages ongoing requirements and corrective action plans
- Work closely with the Senior Clinical Director, Quality and Professional Practice, to ensure action plans and other required information are submitted timely
- Lead the development and implementation of action plans or required follow-up from accrediting organization
- Collaborate with operational leaders and other internal stakeholders to ensure action plans are implemented and processes in place and monitored to maintain accreditation status

**Quality Improvement responsibilities**:

- Support the Quality portfolio in improving clinical processes, practices and clinical outcomes
- Collaborate with business leaders and teams to oversee quality initiatives including but not limited to data measurement, data analysis and internal/external reporting of identified quality indicators
- Support business leaders’ capacity building in patient safety initiatives (e.g. incident reporting education, documentation, analysis, trending, reporting)
- Support the identification and implementation of clinical practice changes to support activities related to quality and patient safety

**Qualifications**:
**Education**
- A regulated healthcare professional holding a current professional license in good standing to practice (e.g. RN, PT, OT, etc.)
- At least 5 years of regulated healthcare professional experience
- Masters Degree (preferred)

**Work Experience**
- Prior experience with regulatory standards is an asset
- Prior experience in quality improvement initiatives
- Experience in risk incident management (e.g. incident analysis, Root Cause Analysis, etc.)
- Preferred: Experience with project management or change management (e.g. Prosci certified)
- Preferred: Experience with Quality Improvement methods (e.g. PDSA, LEAN, Six Sigma)

**Leadership skills**
- Knowledge of Accreditation Canada standards
- Understanding of standards and regulations r